Changes to coverage Population entitlement

Since 1 January 2008, the entire population (almost) has been covered for the same health services. Before that date, the benefits package for most self-employed people and their dependants did not include the so-called small health risks. However, the decision to remove the distinction in coverage between the self-employed and the rest of the population had already been taken before the start of the crisis.

The benefits package

Insurance coverage is uniform for all insured people, who are entitled to the same benefits package in the compulsory health insurance system, with some exceptions.

For example, since July 2007, active bandages and (some) painkillers are (partly) reimbursed for chronically ill patients but not for the general population; in addition chronically ill children under 18 who are treated in rehabilitation centres receive compensation for travel costs (since May 2011). Since the outbreak of the crisis, no measures have been taken to exclude or reduce health services covered by compulsory health insurance. An exception is the health technology assessment (HTA)-determined reduction in the number of conditions eligible for reimbursed oxygen therapy (2012).

User charges

Belgium has a complex structure of patient cost-sharing. Two cost-sharing arrangements coexist: for some services, patients pay a percentage of the price or fee (co-insurance), for example, 25% of the drug price; for others, they pay a fixed amount (co-payment), for example €6 for a general practitioner (GP) consultation. In the period 2008–2013, a number of measures related to patient cost-sharing were introduced. As can be seen from the measures listed in the next sections, there has been an emphasis on trying to minimize financial barriers to accessing health care and to protect vulnerable groups. Although most of these measures were not necessarily a direct response to the crisis and were already being considered before the crisis, they highlight the primary goal of policy-makers.

Fig. 1.2 Public and private health spending in Belgium in 2007 and 2011 as a percentage of total health spending

Source: Assuralia, 2010, 2013.

Fig. 1.3 Spending by sector in Belgium in 2007 and 2011 as a percentage of total health spending

Federal government – social security Federal government – other

GP services

Before December 2011, cost-sharing arrangements for GP office consultations had a complicated structure. They depended on having a global medical record, on eligibility for increased reimbursement of health care costs, on regular or out-of-hours consultations and on GP qualifications. Since 1 December 2011, all co-payments and co-insurance rates for GP consultations were replaced by four co-payments, where the amount of the co-payment depends on the eligibility for increased reimbursement and on having a global medical file.⁸ Also since December 2011, extra fees for out-of-hours consultations are fully reimbursed by the RIZIV. Although the new cost-sharing structure for GP consultations was mainly motivated by reasons of administrative simplification and not to increase financial accessibility to health care, the measure has facilitated the expansion of the system of social third-party payments (see Protection mechanisms, below) (Farfan-Portet et al., 2012).

Medical specialist services

Since 1 November 2010, co-insurance rates for specialist care (40%) are subject to a ceiling of €15.50 for individuals not eligible for increased reimbursement.

Patients eligible for increased reimbursement have much lower co-payment levels.

Dental care

Since September 2005, co-payments have been waived for dental care services for children under 12 years of age. In July 2008, this measure was extended to children up to 15 years of age, and in May 2009 to children up to 18 years. In addition, the age limit for those eligible to have their annual preventive dental check-up reimbursed was raised to 63 years of age in 2012. The co-payment waivers (since 2008) and the expanded check-up coverage have increased public expenditure for dental services for these user groups (RIZIV, 2013d).

Pharmaceuticals

Before April 2010, co-insurance rates for drugs dispensed by community pharmacies were determined by the drug category: 0% for drugs in category A, 25% in category B, 50% in category C, 60% in category Cs and 80% in category Cx. For patients entitled to increased reimbursement of medical costs, the co-insurance rate for drugs in category B equalled 15%. In addition, patient cost-sharing was capped for drugs in categories B and C to avoid large amounts being paid as OOP payments. Due to the new remuneration system for pharmacists, introduced in April 2010 (see section 3.3 on provider payment reforms), the way the level of cost-sharing was calculated for outpatient drugs

8 The global medical file was introduced to increase the availability of medical, social and administrative patient information and access to such information (Gerkens & Merkur, 2010). The ultimate aim of the measure was to optimize primary care quality. The GP holds the file with the patient’s consent and shares relevant information with other providers.

dispensed by community pharmacists had to be adapted. A co-insurance rate as a percentage of the reimbursement basis (pharmacy retail price) was replaced by a percentage of the reimbursement basis factory price (usually equal to the ex-factory price). The main objective of the new reimbursement basis was to keep patient cost-sharing unaffected by the new pharmacist remuneration scheme.

Disease management programme

As a response to the crisis, cost-sharing has been eliminated for services included in the disease management programme (DMP) for patients with type 2 diabetes or chronic kidney failure; both changes introduced in 2009.

For example, financial incentives to enter the programme for type 2 diabetes include total reimbursement of all consultations with the coordinating GP, total reimbursement of consultation(s) with the diabetes specialist, partial reimbursement of dietician and podiatrist consultations, reimbursement of diabetes education and free access to self-management education materials, such as glucose meter, glucose test strips and lancets (Cleemput et al., 2012).

Protection mechanisms

Protection mechanisms have always been present in the Belgian health care system to enhance access to health services for economically vulnerable groups.

However, since the onset of the economic crisis, some additional measures have been added. OOP payments have been estimated to account for about 20% of total health care expenditure. However, the financial burden of the poor and the sick has been shifted to the public authorities by a wide range of protection measures, which can be classified into two groups. The first group consists of measures that reduce the cost of health care for each encounter with the health care system. An example of this is the system of increased reimbursement of medical costs, in which patients with a specific social status (e.g. the long-term unemployed or pensioners with a limited gross taxable household income) or households below a certain income threshold are entitled to reduced co-payments and co-insurance rates. The (social) third-party payment system is another example. The second group of protection measures, such as the system of maximum billing that was introduced in 2002, puts a cap on a patient's total health care costs. Finally, (regulatory) measures to protect patients from supplements that are too high have been introduced since the start of the economic crisis.

Increased reimbursement of medical costs

Financial protection of economically vulnerable patients was already provided for in the first Health Insurance Act of 1963. At that time, vulnerable patients were defined as widows/widowers, orphans, pensioners, persons with disabilities and their dependants. They were fully reimbursed. Over the years, the definition

of the vulnerable population was extended to other groups; the principle of full reimbursement was replaced by increased reimbursement of medical costs (preferential reimbursement) compared with the general population, and eligibility for preferential reimbursement became means-tested. Some people are entitled on the basis of a granted social benefit without conditions based on income; such as people entitled to social integration revenue or social aid from the Public Welfare Centre. Others are entitled on the basis of status as long as their gross annual taxable income does not exceed a certain limit; these include widows/widowers, orphans, pensioners, persons with disabilities or those who have been unemployed for at least one year. Since 1 July 2010, the group of people entitled to preferential reimbursement was extended to include members of single-parent families and the age limit (over 50 years) for the long-term unemployed was abolished. Since 1 July 2011, people entitled to a fund for domestic oil from the Public Welfare Centre are also entitled to preferential reimbursement of medical expenses.

Omnio-status

Already in 1994, the General Report on Poverty (King Baudouin Foundation, 1995) recommended that preferential reimbursement should be given to individuals based on their income and not on social status. However, because of budget restrictions, it was not until July 2007 that the government responded to this report by generalizing eligibility for preferential reimbursement solely based on income by creating the Omnio-status. All patients with a household income below a certain threshold are entitled to Omnio-status and hence to increased reimbursement of health care costs. While take-up of this status was low in the beginning, at the end of 2012 almost 280 000 individuals were registered. On 1 January 2014, eligibility criteria for Omnio-status and for the increased reimbursement based on social status were synchronized.

Extension of the (social) third-party payment system

In general, a direct payment system applies to ambulatory care and the third-party payment system applies to inpatient care and pharmaceuticals. To improve access to health care, the (social) third-party payment system was extended to ambulatory care on 1 July 2011 for some vulnerable population groups, such as people in an occasionally precarious financial situation and people entitled to preferential reimbursement or Omnio-status. Although this measure does not change the amount of co-payments that must be paid, it increases accessibility at the point of use.

Maximum billing system

The maximum billing system puts a ceiling on the total amount of co-payments (excluding supplements and also some co-payments) to be paid during a

calendar year. The maximum share of co-payments as a proportion of total net taxable household income varies between 2.4% and 3.9%, except for the very poor (with a net taxable income below €11 500), where it can be larger than 3.9%, and the very rich, where it can be smaller than 2.4%. The system has been expanded gradually since its introduction in 2002. For example, for chronically ill patients, some non-reimbursed painkillers were included in the calculation of the maximum billing ceiling. Since January 2009, the co-payment threshold has been reduced by €100 for individuals who have exceeded the limit of €450 of co-payments for two consecutive years. These individuals are considered to be chronically ill.

New status for patients with a chronic illness

In September 2013, the status of "chronic illness" was adopted by the government. The status will be automatically assigned by the sickness funds to patients with at least €300 of health care expenses (not only OOP) for eight consecutive trimesters or who are entitled to the lump sum payment for the chronically ill (Dutch, zorgforfait; French, forfait de soins).⁹ Patients suffering from a rare or orphan disease are also entitled to the new status. Patients with the status of having a chronic illness are automatically eligible for the lower maximum billing ceiling (as of 1 January 2013) and for third-party arrangements (as of 1 January 2015).

Supplements

While the system of maximum billing offers protection against the accumulation of co-payments to be paid, it does not include supplements (i.e.

extra-billing above the officially agreed tariff). Supplements in the hospital sector are regulated and registered, but information on supplements charged in an ambulatory setting by doctors who have not signed the fee agreement is currently not available. However, a new law on transparency is in preparation that will require physicians and dentists to mention the exact amount (including supplements) that has been paid by a patient on the medical attestation to be submitted to the sickness fund.

Hospitals and medical specialists can charge supplements on their fees, on the price of the room and on implants and medical devices. In the last few years, particularly since the onset of the crisis, the reimbursement level for implants and medical devices has increased. In addition, the fee and room supplements have increasingly been regulated, which is based on the room type. In 2010, supplementary charges for two-person hospital rooms were abolished. Since 1 January 2013, patients in rooms with two or more people are almost fully protected against fee and room supplements. The only exception is the possibility

9 Patients are entitled to this lump sum payment if the sum of their co-payments has exceeded a threshold in each of the two previous years and they can prove that they have lost their ability to live independently to a major extent.

for medical specialists who have not signed the agreement to charge supplements for day-stay care. However, the National Committee of Representatives of Physicians and Sickness Funds recommends that medical specialists do not charge supplements to patients with preferential reimbursement, chronically ill patients and for day-stay care in oncology.

3.3 Changes to health service planning, purchasing and delivery